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Post Marathon Recovery: How to make sure your last marathon isn't your last marathon!

By Dr. Marc Bochner

It’s November, and many runners have just finished a fall marathon. For some it may be their first, others may have raced to a personal best. Hopefully, you finished “feeling good” and that feeling has carried over into your recovery period. However, if you plan to jump right into heavy training again, you may be in for trouble in the months ahead, in the form of injury or “burnout” from running. Here is some information you can use to ensure that your last marathon won’t be your last marathon.

No matter if it’s your 1st or 50th marathon, a certain amount of time is required for our bodies, and minds (not to mention family and friends), to heal before the next race or season.


Understanding just what recovering means when it comes to exercise in general and actually a race of any distance, not just a marathon, can help with planning you’re next few weeks and months.  After any exercise session, our body systems- musculoskeletal, hormonal/metabolic, nervous, immune- are stressed and must adapt to be ready for the next bout of exercise.  Of course, a marathon will cause more damage and need a longer recovery time than a shorter race. Other stressors, such as lack of sleep, poor nutrition, work or family obligations- can also combine with the exercise session to stress these systems.  We must monitor our response to these stressors as well to exercise, when planning our post-exercise recovery. No matter if it is a hard workout or a marathon, the same principles apply. 

Post-race recovery can be broken up into 4 stages: the immediate hours after the race, the first week, the first month, and returning to regular training after the first month. This article will assume you successfully navigated the immediate post-race walk, hydration, and nutrition and the rest of your marathon Sunday and did not have an acute injury or medical condition.

For the musculoskeletal system, the monitoring during the last three recovery stages can be as simple as charting your post-exercise soreness levels during regular daily activity such as walking, and also ranking your tenderness to touch.  Often after exercise that stresses our bodies past current ability levels, the maximum soreness will not occur until about 48 hours after the exercise session.  This is called “delayed onset muscle soreness” or DOMS. However, by three or four days after the race, this soreness should be dissipating. Thus, if you are still experiencing significant soreness with daily activities (walking downstairs and bending your legs to squat, for example) after the third of fourth day post-event, you may be recovering slowly the first week. And, if you have soreness or tenderness to the touch that is only on one side of your body, this may be the first sign of a developing injury, as DOMS is usually bilateral and equal in intensity and duration on both sides.  If high impact exercise such as running is resumed too early in this healing process, the soft-tissues that are still in a weakened state will not have the strength to resist more muscle/soft-tissue damage and recovery can take longer and injury risk can be higher. 


To help athletes and patients in general self-monitor their recovery from regular workouts and from races such as the marathon, in addition to monitoring the post-injury return to exercise such as running,  I have developed an online training long and electronic health record system called traininghistory.com.  Training History includes an “Activity Readiness Score” which takes into account not only injury symptoms, but the underlying status of your muscles. Often injury will occur or re-occur if non-symptomatic muscle dysfunction in not identified and treated. The goal of training history is to provide a method for you to note when key areas that may lead to injury are dysfunctional, before the full injury develops.  For post marathon recovery, this score can be valuable as it can help you take some of the guesswork out of planning your return to exercise and running.  The self-monitoring muscle dysfunction ranking for the Activity Readiness Score is as follows:

Level 1:  None= little or no soreness to even heavy touch/stretching/motion.

Level 2: Mild= mild soreness to medium to heavy touch/stretching/motion.

Level 3: Moderate= moderate soreness to light touch/stretching/motion.

Level 4= Severe= severe soreness to even light touch/stretching/motion.

Now, to the specifics of the post-marathon exercise plan for the first week and month. Light stretching and walking for regular daily activities is fine for the first few days and will help circulate blood with healing nutrients as well as remove waste products. If you have a foam-rolling and self-massage routine that you follow, you can use that routine as a self-monitoring tool. Just be careful the first few days post-race (those with low pain tolerances will not want to go near their rollers much the first week). For everyone, waiting at least one week before running again, or doing other lower body aerobic exercise (even the elliptical) is a wise choice.  Those who were either under-trained or over-trained, raced beyond their fitness level, or were fighting a specific injury before the race may need more recovery time than the more properly prepared and/or experienced runners. Using the self-monitoring system described in the previous paragraph, if you are still a 3 or 4 on the muscle rating scale, meaning you have moderate to severe soreness to just light touch or with light motion, you should not be doing running or other weight-bearing impact exercise yet no matter how many days have passed since the race. Just regular light walking during your daily activities should continue. Non weight-bearing exercise such as swimming may be OK. 

Once you score a 1 or 2 on the scale, which usually will be after about a week, then you can hit the elliptical or other non-impact exercise and try easy running. If your legs still fell heavy, lifeless, and sore after a week of light runs or workouts, continue to go easy or take some more rest days. If not, you can run a little faster and longer and more frequent the third week.  By the fourth week, you can run almost normal pace, distance and frequency for weekday runs, but you should not run a long run similar to your long runs in training or increase your mileage to “base building” levels.  Information on the return to regular training after the first month is given near the end of this article.

If after 7-10 days you are still experiencing any specific soreness with motion or tenderness to the touch, and are still a 3 or 4 on the muscle recovery scale, it may be wise to see your sports doctor for an exam to rule out a specific injury.  A post-race massage and/or chiropractic treatment is a good idea in any case at this point. Also, if you were injured during training and still did the race, or want to prevent future injury, scheduling a visit for a full sports chiropractic biomechanical analysis and treatment plan to correct any imbalances and altered movement patterns is essential. My Prepare to Compete© program has helped many endurance athletes use their “off-season” to work on their weakness and injury-proof their bodies.  It is difficult to correct imbalances during the intense training and racing parts of the year, so once you are past the one month recovery point after the marathon, such a rehab/prehab program can begin.


Finally, to plan the rest of your marathon recovery past the first month, and to avoid injury and recover fully, it may be helpful to think of the training year as a continuous circle, with the day after your last big race as the first day of the next season. This is because what you do now will determine what you can do over the winter months, which will then determine what type of shape you are in when your next race arrives. If you are planning to run some “off-season” winter races, even just for fun (which can be a good idea to help you avoid the post-marathon winter “blues”) you should keep some type of aerobic base. Most should decrease their weekly mileage and add some other forms of aerobic activity, such as swimming, cycling, deep water running, or cross-country skiing.  Those who enjoy downhill skiing or snowboarding can fill in the added non-running weekend days with those activities. And if you like to play a sport such as tennis, or even basketball, those can help maintain fitness as long as you are careful and gradually get used to moving laterally and with quicker movements. In addition, an weight-training program that includes upper body and core (from the hips to the shoulders) strengthening should be part of you winter fitness routine, and range of motion work such as yoga should be used as part of this routine. “Functional exercises” such as single leg squats, lateral lunges, single leg deadlifts and plyometric exercises can also be utilized once any weak links and imbalances are rehabbed with a program like Prepare to Compete.  Traininghistory.com also has a full prescription of recovery, correction, rehab and fitness exercises for each stage of recovery and for the racing season.

When should you start transitioning back to a more running-centered plan and increasing running mileage again? The answer depends on what your goals are for next year. Those who plan to “peak” for two marathons next year, one spring and one fall, such as Boston and New York, or have an early season triathlon, will want to start building a base earlier, such as January. But even if you are not racing “long” until next fall, don’t wait until July to start building back your base, as you will leave less room for error and more room for injury. Ideally, for a fall marathon, you should reach half-marathon distance by the end of May, no matter what your ability level.

 If you follow these steps, chances are you will avoid the common post-marathon injuries that often appear in the winter months, such as iliotibial band syndrome and stress fractures. Better yet, you will enjoy your winter racing or cross-training, and you will have both the body and the energy to “reach new peaks” next year.


Last-Minute Marathon Advice

Running the NYC Marathon on Sunday, November 3rd? Some tips to remember:
1) Race week is not for training! If you have prepared properly, this week a few very short, 2-4 mile runs are all you need. All of the training you have done in the last few months is “in the books” and will serve you well on Sunday. If you have missed some workouts, it is too late to make them up; rest your legs! runner_stretching

2) Tapering “pains”—If you are unsure if an ache or pain is an injury in the making, pre-race nerves or “tapering stiffness,” and wondering if you should see a doctor? The answer is probably “Yes” if any of the following conditions exist:

A) The area has “soreness to the touch” that is more intense than your usual post-workout level and lasts days after the last run. B) The area is swollen. C) The area is painful and/or restricted with normal movements. or D) You are unable to bear normal weight on the injured side.

If any of these symptoms are present, you may have an injury brewing and at least need some reassurance that you can still race with last-minute treatment and advice. If you are just a little sore and none of the above is occurring, just keep up your normal stretching/foam-rolling routine if you have one, which will keep key muscles loose and ready, even on days you are not running. And if you currently have a “maintenance routine” of massage and/or chiropractic soft-tissue and joint care, keep it up as you usually do. Earlier in the week of course is better in either case—last-minute appointments can be hard to find marathon week in NYC!

2) Visualize your race weekend ahead of time, and the race itself. Plan early what you will wear for different weather conditions, your pre race meals, what time you will get up race day, and what gels, etc. you will use. Then, picture yourself running according to your plan for each part of the course, not anyone else’s! General pace tip: In NYC, with the super enthusiastic crowds, it is easy to “go out” too fast, and the 2nd half of the course has the bridges and more challenging uphill sections. So while you don’t want to go to slow in the first half, remember to pick a pace that will leave you with energy for the final 10K.

marathon group3) All endurance races have “rough patches” we must get through. When you face some challenging miles, for a confidence boost, remember back to your tough training runs and how you overcame and finished them. Thinking of your personal motivation for running the race in order to remind you why you are out there and how you are lucky to be where you are right now also can help. Also, it may be cliché, but “take it one step at a time” and focus only on the few blocks ahead of you (easy in the NYC marathon with our numbered streets along most of the course) instead of the total distance to go. In most cases, before you know it, you will be feeling better and be able to let your mind wander a little bit if you want to.

If you really do not feel well, there is plenty official medical help on the course at the aid stations to help you—don’t be afraid to stop and let the staff help you out—that’s what they’re there for.

4) Finally, calm your body and mind: relax your leg muscles later in the race by focusing on “running from your core” by rotating from your hips and pelvis, and relax your mind by taking one mile at a time and enjoying the best day of the year in NYC!

This article is for informational purposes only. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.


"In the Neck of Time": Proper Treatment and Prevention of Neck Pain

 The neck is one of the most commonly treated areas in chiropractic. One estimate puts the incidence rate in the last 3 months at almost 14% for adults. (Spine (Phila Pa 1976). 2006 Nov 1;31(23):2724-7.   However, there are many cases of neck pain that are either not treated until further, "harder to treat" pain ensues or are treated with less effective means of treatment.  This lack of proper treatment may be due to a lack of awareness of proper neck function as well as an underestimation of the long-term consequences of a minor neck injury.  This is unfortunate, as a healthy and mobile neck is essential for a healthy and mobile life.  Part 1 of this article will explain the causes and categories of neck injury.  In Part 2, the proper diagnosis, treatment and prevention of the most common neck conditions will be discussed, so that you can manage your neck pain proactively, instead of "in the neck of time", when more severe conditions may already have developed.

First of all, let’s start with a little discussion of neck function and anatomy.  The "neck" actually refers to the cervical spine and the structures that both pass through and attach to it.  This includes the 7 cervical vertebrae, which are bony structures, and the fascia (connective tissue), ligaments, tendons, arteries, nerves, veins and glands attached to them. And as the neck also includes the spinal cord and nerve roots passing through and letting the brain communicate with the rest of the body, one can not underestimate the importance of a properly functioning cervical spine. There are both deep and superficial layers of neck muscles:


Superficial Neck Muscles

Functionally, the cervical spine of course supports the head and jaw, and allows us to both have an upright posture to use the organs located in these structures (brain, ears, eyes, nose and throat) as well as allowing for freedom of mobility for turning to move with the rest of the body and for visualizing our surroundings.  Without proper cervical spine function, the nerves passing between each vertebrae can become compromised, and so can the spinal cord.  Normal cervical spine range of motion is about 50 degrees flexion (bending your neck forward), 85 extension (backwards), 90 left/right rotation, and 40 lateral flexion. When we move and perform everyday motions as well as take part in athletic activity, we actually use "coupled" motions of more than one of these at a time.  Until one has an injured neck and loses mobility, the amazing functional capabilities of the neck region are often taken for granted.  For example, few gym exercise routines dedicate exercises to the neck region.  And without proper neck rotation, safely operating a motor vehicle, bicycle or even walking is very difficult as turning to see your surroundings and traffic can be limited.

Also often evaluated in cases of neck pain are the head, jaw, and shoulder complex.  And, for a complete biomechanical exam the thoracic and lumbar and pelvic regions as well as the lower extremity should be evaluated as all the regions of the spine and the extremities are connected through kinetic and myofascial chains, as well as neurologically.
Causes of Neck pain and injury: 

There are two major categories of neck injury, just as in most musculoskeletal injury: both acute or "traumatic" injury as well as "chronic" or overuse injury occur in the neck region. However, often what may appear to be an acute or sudden injury may be the result of years of neglect of a lower-level chronic injury that finally results in an acute, highly painful and disabling injury.  This is often the case with the increasingly sedentary nature of our daily lives.  And, as children are using electronic devices as early as after only a few months of age, the age of onset of some neck injury is much earlier than in the past. Also, youth sports such as soccer (heading the ball), football, wrestling and gymnastics all can result in neck injury.

Thus, since there can be overlap between the acute and chronic injury, with an ongoing chronic condition occasionally causing acute episodes of more severe pain and dysfunction, it is useful to categorize neck injury into three categories or "stages" based on the degree of tissue involvement. These 3 stages are:

1) Postural strain and deconditioning: This stage is characterized by local pain that occurs as muscles and connective tissue are stressed by overuse of certain postures and lack of full range of motion on a daily basis. Think of the poor computer or sitting posture with the shoulders rounded forward and the head extended on the neck. Or the flexed neck posture of constantly using your cell phone for texting and emails. Some muscles shorten, some weaken, blood flow decrease, and joints stiffen. Symptoms are stiffness, burning pain in muscles, and muscles and joints that are very tender to the touch.

2) Mechanical Dysfunction: "subluxation" or "joint dysfunction". This stage can either be a progression of poor posture leading to the spinal joints losing proper alignment and motion, or an acute injury that may occur more easily on the now de-conditioned cervical spine and musculature. Either case can then cause both local and referred pain down the arm or back or into the head or jaw, from the muscles and joints or from actual nerve irritation. X-rays will show altered alignment and motion but MRI studies may be normal. If left untreated, structural changes start to occur in the spine and ligaments that may not be fully reversible. This degenerative process is often considered part of “normal aging” but the rate of progression of this process is accelerated by leaving these joint and muscle dysfunctions untreated. This can eventually lead to significant pain and functional limitation, especially if the third stage of neck injury is reached.

3) Degenerative Conditions of the Discs and Joints with or without spinal nerve root or spinal cord involvement:  

If the 2nd stage of neck injury is not treated properly, often the neck will start to display structural changes in response to the chronic stress of poor posture and altered spinal biomechanics. Diagnostic imaging studies (x-rays and MRI’s or CT scans) will show not only the altered posture and vertebral alignment, but degeneration of the intervertebral discs, disc bulges and herniation, and arthritic changes to the spinal joints. Joints can become unstable, and both the spinal cord and nerve roots can become irritated. Symptoms can now include more severe nerve pain, numbness and muscle weakness in the upper extremity or even lower extremity. The good news is that although these structural changes may be present, often if the underlying postural stress and deconditioning of Stage 1, and the mechanical dysfunction of stage 2, are addressed, the clinical significance of the degenerative changes can be minimized.

As we age, the likelihood of progressing through all of the stages of neck injury is greater.  However, as will be explained in Part 2 of this article,  if you take action and get timely treatment and follow proper "neck protective" daily habits, when it come to this area of the body you will be "in the neck of time" avoid activity and lifestyle limitations due to a "pain in the neck".  Check back for Part 2 next month!


Sitting Fit: Prevent "Movement Dystopia" 

In a 2012 study, "Too much sitting--a health hazard" by Dunstan DW, Howard B, Healy GN, Owen N.in the journal Diabetes Research and Clinical Practice, (Diabetes Res Clin Pract. 2012 Sep;97(3):368-76) the authors found that sedentry lifestyles are "adversely associated with health outcomes, including cardio-metabolic risk biomarkers, type 2 diabetes and premature mortality" and that "Importantly, these detrimental associations remain even after accounting for time spent in leisure time physical activity".

What this means it that many studies have demonstrated that because our lifestyles in general have become so sedentary, this trend is a health risk even among those who exercise vigorously for an hour a day. The authors demonstrate that "light activity" is very valuable in disease prevention, and that our time spent in light activity, even among exercisers, is too little.  The authors recommend an increase in light activity to break up periods of uninterrupted sitting. I have termed this lack of motion, along with relatively narrow variety of motions in many exercises people do perform, "movement dystopia." Not only does prololonged sitting increase cardiovascualr disease risk, but many musculoskeletal injuries such as neck and shouder pain, wrist pain and "Carpal Tunnel Syndrome" and lower back pain are also more prevelant in those who are more sedentary.

How can we prevent these negative effects of sitting and create or own "movement utopia" in the midst of the computer age?  Here is a summary of which muscles get tight with prolonged sitting, and some simple advice on taking breaks and stretching at your desk:

 Muscles that get tight:

  •   lower hamstrings, calves
  •    upper thigh (hip flexors)
  •    inner thigh (hip adductors)
  •   front of chest/shoulder
  •   forearm/hand muscles

Recommendations to keep the body feeling good at work:

  •   Take hourly breaks at least two minutes long (stand and take a walk around the office).
  •   Head to the gym during lunch.
  •   Stretch at your desk.

Stretching at Your Desk:

1) Leg Extensions (stretches hamstring/calf):

While at your desk, sit up straight with both feet on the ground. Keep your lumbar spine in neutral (slight arch in your back and lower abs tensed to activiate your core). Extend one leg at the knee until it is upright, parallel to the floor. Then add further stretch by flexing your foot towards you. Hold this position for three to five seconds and repeat five times on each side.

  2) Chair Lunge (stretches hip flexors):

Place one leg forward with foot resting on a chair (preferrably one without wheels!). Extend the upper trunk, while slowly moving the pelvis forward. Do not bend at the waist; the movement should be at the hips. Hold this position for three to five seconds and repeat up to five times on each side.

  3) Shoulder Stretch (front of chest/shoulder) :

Stand in a modified "fencers' stance", with one leg about 6 inches in front of the other and both knees slightly bent. Raise the arm on the rear foot side out at your side, 90 degrees to the body and bent at the elbow, with your forearm parallel to the floor. From that position, rotate your arm externally until the forearm is perpendicular to the floor. Repeat five times on each side, holding each for 2 to 3 seconds before returning the arm to paralled to the floor.

  4) Forearm Stretch- Keeping carpal-tunnel syndrome at bay:

Stretch one arm out in front of you, elbow straight and palms up. Grab the fingers of the outstretched hand with the other hand and pull back, feeling the stretch in the hand and forearm. Hold for 10 seconds, alternating sides. Next, bend the arm at the elbow to 90 degrees, still with your palm to the ceiling. Again grab the fingers with the other hand and pull back, feeling the stretch in the hand/fingers. 

  5) Bonus Stretch- Keep your fingers strong:

Place a wide rubber band around the tips of your fingers. Close and open your hand mimicking 'Pac-Man". This move will stretch your fingers and thumb and is especially helpful if you use your mouse a lot.

This article is for informational purposes only and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.



Prepare to Compete: Avoiding Movement "Dystopia"